Understanding complexity in palliative care is crucial to address local and systemic barriers to palliative care provision and to enhancing quality of care for patients. Critical to this understanding are palliative care clinicians’ experiences of complexity in their work; however, existing frameworks have not explored these narratives in-depth. Therefore, this dissertation study sought to explore and understand contributors to complexity in hospital palliative care from the perspectives of those who both engage in, and interact with, its provision.

Constructivist grounded theory methodology guided the study’s design. 26 interviews in-depth, open-ended interviews were conducted and the sample included palliative care clinicians, clinicians who request palliative care consultation, and those with administrative roles in palliative care. Consistent with grounded theory methodology, transcripts were analyzed using techniques of constant comparison and intensive memos to construct a theory grounded in the voices and actions of participants.

The analysis revealed that discord is at the heart of complexity in palliative care. Salient dynamics of discord in this sample included conflicts of preferences, beliefs, values, expectations, and perceptions. Such discordant dynamics could involve any number of individuals and/or entities, including patients, family members, clinicians, administrators, palliative care clinicians themselves, as well as structures of value and power. Further, complexity in palliative care was conceptualized as a multiphase process in which palliative care clinicians cultivated relational infrastructures using relational fluency. Relational fluency was defined as a mindset and a skillset in which palliative care clinicians integrated their skills of attunement with various strategies to evoke resonance in themselves and in others. Enacting this process enabled palliative care clinicians to reveal and navigate dynamics of connection and discord often difficult-to-see, obscured, or invisibilized in practice.

This dissertation provides insight into the complexity of palliative care, from the perspectives of those who experience, engage with, and navigate it each day. The findings offer a springboard from which future work may seek to measure complexity in palliative care to inform such processes as resource allocation. The findings also have implications for work that explores goal-concordant care, an important quality metric in palliative care that lacks well established theoretical grounding. Lastly, the content of the discord revealed and navigated by palliative care clinicians in this study may inform future work to guide policy and improve palliative care practice environments.